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National Readmission Conference May 7 th, 2014 June Simmons, CEO Partners in Care Foundation Care Transitions: Strategies that are Working

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Partners in Care Foundation Who We Are Partners in Care Foundation is a non-profit center of innovation whose mission is to change the shape of health care. We pursue our mission by developing and advancing transformational models of care that promote health, independence and quality of life

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Health Reform: Moving From Volume to Value Infrastructures and reimbursement are transforming; emphasis on prevention Major consolidation unpredictable future The roles of hospitals, physicians and payers are blurring The role of the community agency is growing New broader partnerships are essential

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Social Factors and Health Outcomes Societal-level social determinants have individual-level impact 1 Gallant MP. The influence of social support on chronic illness self-management: a review and directions for research. Health Educ Behav. 2003;30(2):170-95.; DiMatteo MR. Social support and patient adherence to medical treatment: a meta-analysis. Health Psychol. 2004;23(2):207-18.; Krieger J, Higgins DL. Housing and health: time again for public health action. Am J Public Health. 2002;92(5):758- 68.; American Public Health Association. The hidden health costs of transportation. http://www.apha.org/NR/rdonlyres/A8FAB489-BE92-4F37-BD5D- 5954935D55C9/0/APHAHiddenHealthCosts_Long.pdf. Published February 2010. Accessed January 10, 2012.; Centers for Disease Control and Prevention. CDC health disparities and inequalities report U.S. 2011. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2011.; Robert Wood Johnson Foundation. Overcoming obstacles to health care. www.commissiononhealth.org/PDF/ObstaclesToHealth-Highlights.pdf. Published February 2008. Accessed January 10, 2012.; Shi L, Singh D. The Nations Health. 8 th ed. Sudbury, MA: Jones and Bartlett Learning, LLC; 2011. IssueOutcome Low education, lack of social support, and social exclusion Poor self-management 2 and reduced care plan adherence 3 Housing 4 and transportation 5 issues Increased health care costs and utilization Health disparities and psychosocial issues Preventable hospitalizations 6 and mortality 7

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Low Ratio of Social to Health Service Expenditures in U.S. Bradley E H et al. BMJ Qual Saf 2011;20:826-831 Copyright BMJ Publishing Group Ltd and the Health Foundation. All rights reserved.

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Health Cares Blind Side RWJF Survey of 1,000 PCPs: 86% said unmet social needs are leading directly to worse health. 80% not confident in their capacity to address their patients social needs. 76% wish the healthcare system would cover cost of connecting patients to services to meet health-related social needs. 1 of 7 prescriptions would be for social supports, e.g., fitness programs, nutritious food, and transportation assistance. Health Cares BLIND SIDE - The Overlooked Connection between Social Needs and Good Health, Robert Wood Johnson Foundation, December 2011, http://www.rwjf.org/content/dam/farm/reports/surveys_and_polls/2011/rwjf71795 http://www.rwjf.org/content/dam/farm/reports/surveys_and_polls/2011/rwjf71795

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Because of the Concentration of Risk and Spending, Home and Community Care Principles and Practices are Central to Improving Quality and Reducing Cost

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CBOs as part of the healthcare system CBOs need to play a new role connecting the home with the healthcare system Home provides unique perspective otherwise unavailable to healthcare providers. Quality measures for health plans and providers relate to issues such as medication use and fall prevention HEDIS, Medicare Advantage Star Ratings Meds are major factor in readmissions home is key New focus on population health identifying and proactively addressing health for high-risk patients

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Home and Community Based Services (HCBS) are High Value Improves quality: Staying home is concordant with peoples goals. Evidence-based interventions like HomeMeds, Stanford self-management programs and care transitions programs reduce ED & hospital use Based on 25 State reports, costs of Home and Community-Based LTC Services less than 1/3 the cost of Nursing Home care.

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Health Care + CBO/Social Services = Better Health, Lower Costs Address social determinants of health Personal choices in everyday life Isolation, family structure/issues, caregiver needs Environment home safety, neighborhood Economics affordability, access Social service agencies have advantages Trust, time to probe, different authority Cultural/linguistic competence Lower cost staff & infrastructure High impact evidence-based programs

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Readmissions: Social Issues Compassionate admissions elder with no caregiver Gentleman with mild cognitive impairment tries to be adherent by taking all meds including sleepers at breakfast starts falling Appointment made by hospital but daughter cant make it no transportation Cant afford meds No food in home especially none that matches diet orders

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Role of Agencies like Partners in Care Eyes and ears in the home Skilled at building trust and relationships Gather data and information that is not shared in a medical setting or encounter Link in medication issues with evidence based intervention Cultural competence in local communities Comprehensive psychosocial & environmental evaluation Attention to caregivers special services, support, respite

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Major Causes of Readmissions and what CBOs can do about them Patient and family lack of understanding about managing patient conditions Provide information about red flags and self-care Missed post-discharge physician appointments Transportation assistance; consider family schedules Medication errors Misunderstanding, language barriers, affordability, multiple prescribers meds already in the home, OTCs Lack of communication among providers after the discharge Patients coached to share information with PCP Lack of food or inappropriate diet Arrange home-delivered meals for special diet

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Care Transitions Coaching & Support Evidence-based home & social services models proven to reduce readmissions Medication Review: HomeMeds SM or HomeMeds-Plus to include comprehensive psychosocial & environmental evaluation Coaching (Coleman Care Transitions Intervention) for those who are capable (or have caregivers) Social services (Rush U. Med Center Bridge Program) for those who are not Connect patients to services and supports for recuperation, rehabilitation, education

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Partners HomeMeds SM -Plus Program DescriptionOutcomes/Experience Comprehensive assessment Meds, ADL, PHQ-2/9, cognitive, sensory, social & behavioral health indicators Comprehensive report, service plan for LTSS, self-management & behavioral health HomeMeds SM Pharmacist review Contact with members physician and other health providers Compared to those who screened in and didnt get the intervention: Readmission rate 22% lower ED use rate 12.7% lower ROI = 53% (net) 63% post-acute had med-related problems. 77% had a home safety issue 54% had other issues (financial, caregiver, depression, etc.) 9% had depression

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Medications & Care Transitions 72% of post-discharge adverse events are related to medicationsand close to 20% of discharged patients suffer an adverse event. * 35% of Medicare patients taking 5 or more medications experience adverse drug events* HomeMeds program a social work solution *Mary Andrawis, PharmD, CMMI, presentation to Drug Safety Panel, May 10, 2011 (Forster et al., Annals of Internal Medicine. 2003; 128: 161-167./ CMAJ FEB 3, 2004;170-3)

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HomeMeds - Bridge between Home and Healthcare HomeMeds is designed to enable community agencies to keep people at home, out of hospital & nursing home, by addressing medication safety Practice change with workforces that already go to the home more cost effective use of existing effort Targets problems for significance, accessibility to in-home staff, and likelihood of positive prescriber response. Focuses on adverse effects (falls, confusion, dizziness, vitals) then determines if medications may be part of the cause. Cost-effective use of geriatric pharmacist for complex problems

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HomeMeds-Plus Targeting Criteria 1.Age 65+ and 2.ED/hospital use in 6 months, plus 2 or more: a)Hospital LOS > 6 days; or b)Six or more prescribed meds; or c)Warfarin/antiplatelet or insulin/diabetes meds; or d)Dx CHF, COPD, depression, anxiety, bipolar, psychosis; or e)DX of diabetes, dialysis, hemodialysis, renal failure, CKD, ESRD, CAD, COPD or CHF; or f)Mild cognitive impairment; or g)Recent treatment for fall or confusion; or h)Age 80+; or i)Limited caregiver support

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Adherence Problem: 4 prescriptions patient says yes when pharmacy calls for refill obviously not taking meds Meds in the Home 101

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Spanish speaker English labels Neighbor helping Bottles get moved Trouble ahead! Meds in the Home 101

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Patient stored all morning meds in the same container Meds in the Home 101

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The Role of Caregivers Family Caregivers 1 Adult children, spouses, other relatives, friends/neighbors Older adult spouses at risk for physical & mental health issues 46% of family caregivers perform medical/nursing tasks for relative with multiple physical and cognitive conditions 78% manage medications 60% report learning how to manage medications on their own 47% said they NEVER received training from any source. Paid Caregivers 60% in recent study could not fill pill box correctly 1/3 had difficulty reading and understanding health information 1.Home Alone: Family Caregivers Providing Complex Chronic Care. AARP. October 2012 2.Inadequate Health Literacy Among Paid Caregivers of Seniors. J Gen Intern Med. 2011 May; 26(5): 474479.

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Addressing Readmissions through a Comprehensive, Coordinated Delivery System

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Managing Readmissions Not Easy Alone HSAG finds 27.5% readmitted to a different hospital Efficiency demands coordination and a broader geographic approach Many issues NOT in skill set of healthcare It takes a multi-pronged approach Hospital Home Health SNF CBO PCP, etc.

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Bringing Local Person-Centered Services to Large Regional Systems National movement to change the business model of the Aging & Disability Services Network U.S. Administration for Community Living (ACL) Add upstream value to save downstream costs Local knowledge, trust, experience Low-cost models Buthow do you create an efficient system with dozens of smallish agencies?

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A Possible Solution: Led by ACL & the John A. Hartford Foundation Initiative Overview CBO networks to create an integrated system of non- medical care and services Contract with healthcare organizations (Medicare Advantage, Medi-Cal managed care, duals plans, large medical groups, ACOs/Medicare Shared Savings, commercial insurance) Measure & document value added National dissemination & technical assistance

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Care Transitions SoCal Glendale Healthier Community Coalition - Glendale Hospital plus Partners in Care and 2 additional hospitals Hollywood Area - AltaMed Health Services Corp plus 4 hospitals Kern/Bakersfield: Partners in Care + 5 hospitals Orange County Care Transitions Partnership - SeniorServ plus 4 hospitals San Diego Care Transitions Partnership - AAA plus 11 hospitals San Fernando Valley Transitions Coalition - LA Jewish Home plus 3 hospitals Ventura County Care Transitions Community Partnership - AAA / Camarillo Health District plus 5 hospitals Westside Care Transition Collaborative - Partners in Care+3 hosp

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My coach helped me make continuing health a priority and having her support made me feel important despite my age. Patient Lolita Regional network covers LA, Ventura, Orange, San Diego & Kern Counties Hospital-to-home coaching for optimal post-discharge recovery Patient empowerment: PCP follow-up, meds management, ER avoidance education, healthy behaviors activation Contracted to serve 40 hospitals Served 1,000s of patients in first year Projected results: 20% reduction in FFS Medicare readmission rate

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Self-Management Support The actions that individuals living with chronic conditions must do in order to live a healthy life. Problem-Solving Planning Physical Activity Managing Fatigue Medications Working with Health Professionals Family Dynamics & Support Managing Pain & Symptoms Communication Healthy Eating Understanding Emotions

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High-Level Evidence-Based Programs Offered by CBOs SELF-MANAGEMENT Chronic Disease Self-Management Tomando Control de su Salud Chronic Pain Self-Management Diabetes Self-Management Program PHYSICAL ACTIVITY EnhanceFitness & EnhanceWellness Healthy Moves Fit & Strong Arthritis Foundation Exercise & Walk With Ease Programs Active Start Active Living Every Day MEDICATION MANAGEMENT HomeMeds FALL RISK REDUCTION A Matter of Balance Stepping On Tai Chi Moving for Better Balance DEPRESSION MANAGEMENT Healthy IDEAS PEARLS CAREGIVER PROGRAMS Powerful Tools for Caregivers Savvy Caregiver NUTRITION Healthy Eating

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Diabetes Self-Management Program Developed at Stanford by Kate Lorig, RN, Dr.PH Patients learn to take control of their diabetes. Peer-led workshop develops tools to: Learn about disease & self-care & monitoring Understand and deal with emotions Manage medications Work with health care providers Make action plans for exercise and healthy eating One year after 6-week workshop: Improvements in stress management, self-reported health, aerobic exercise, health distress, self-efficacy, communication with physicians Fewer hospital days; more PCP visits

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Chronic Pain Self- Management Program Medication isnt the only treatment. Developed by Stanford & Memorial Univ. of Newfoundland Patients learn to manage & decrease chronic pain. Outcomes: Less Pain & Lower Dependency on Others More Energy Improved Mental Health Increased satisfaction with life More involvement in everyday activities

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Contact Us June Simmons, CEO Partners in Care Foundation 732 Mott St., Suite 150, San Fernando, CA 91340 Main #: 818.837.3775 jsimmons@picf.org www.picf.org www.HomeMeds.org